Analysis Risk Management System In this instance, the company did not have a specific policy concerning crew hiring and training. A good understanding of the shipboard operating systems and vessel operation would have provided the ship's complement with information to help handle an on-board emergency and a better appreciation of the developing emergency situation. Since there was no on-board inspection regime, the operation of the high water alarm system was not checked regularly. Consequently, the crew did not know that the only mechanism that could provide a remote warning that the vessel was flooding was non-operational. They were operating under a false sense of security. Any decisions made to ensure proper safety management must consider all aspects of the vessel's operation. The decision to reroute the vessel to pick up personnel did not consider the vessel's operational limitations, namely, that the liferaft capacity was seven people. The decision was taken despite the fact that the company knew that the capacity of the vessel's lifesaving appliances must accommodate every person on board. TC acknowledges the benefits of a structured process to identify and reduce risks. The Department ordered a study to examine the application of a safety management system for Canadian commercial vessels that are not required to conform to the International Safety Management Code.7 The study, which was completed in May2004, recommends a two-pronged approach: one system applicable to commercial vessels with a gross tonnage exceeding 15and another for vessels carrying more than 12passengers. The study showed that many occurrences involving small vessels could have been avoided by the implementation of a safety management system. The study also pointed out that the fisheries sector had the highest accident rate. Because the shore-based personnel and the crew worked independently of each other, they were not able to benefit from a coordinated, structured approach. Flooding of the Compartments The flooding of the compartments was gradual. Starting the seawater circulation system caused the water being pumped by the system to fill the live-well tanks. Because the sluice valves were open, this water then drained into the fish hold. The water that accumulated in the fish hold then drained by gravity into the lazarette since the sluice valve connecting these two compartments was also open (seeAppendixB). The partial flooding of the fish hold and the lazarette caused the after part of the vessel to trim further by the stern submerging the six seawater discharge ports of the live-well tanks in the transom. Since the discharge valves were open, gravity caused the seawater outside the vessel to pour directly into the live-well tanks, thereby increasing the flooding in the live-well tanks and the fish hold causing the vessel's stern to sink even more. The situation was further exacerbated when the fish hold hatch cover was lost overboard. Downflooding ensued, and opportunities to control the situation were lost. Furthermore, the potential for losing any remaining reserve buoyancy also existed. The 25mm sill of the superstructure's aft door was below the 300mm required by regulation. The low sill could have facilitated downflooding into the engine room and crew's accommodation. Although the PersistenceI developed a pronounced trim by the stern, it remained afloat. The vessel was maintained in this precarious state of stability and reached home port because a balance was attained between the downward force of gravity produced by the PersistenceI's total weight (that is, the vessel, cargo, people, and water) and the upward force produced by the propeller's propulsion. Deficiencies in Training for Fishers During the investigations into the sinking of the Nadine in December 1990,8 the sinking of the scallop dragger CapeAspy in January 1993,9 the major water ingress on the AlexB.1 in September2001,10 and the capsizing of the CapRougeII in August 2002,11 the Board noted training deficiencies, in particular concerning stability. In1993, the TSB recommended that TC develop and apply measures within its mandate to ensure that owners, operators, and masters (operators) of fishing vessels receive proper training. Despite TC's good intentions to reinforce the examination requirements for operating small fishing vessels, many fishers are not subject to the Department's examination regime because they are not required to hold a certificate to operate a small fishing vessel, as was the case with the PersistenceI. In the three flooding occurrences on the PersistenceI, the vessel had different operators. In this instance, it was the operator's first experience on this vessel. There had been no transfer of information from one owner to the next, or from the company to the crew. This may result in safety-critical decision making based on incomplete information. It is essential that owners ensure that their crews have all pertinent information on the operation of the vessel and on its limitations, so that they can make fully informed operational decisions. Because the inspection certificate was not posted, the prohibition against using the live-well tanks was not available to the operator and crew. If the certificate and its annotated warning had been available, the operator and crew could have made a more informed decision about using the seawater circulation system. Notwithstanding the operational limitation set forth in the vessel's certification, on three occasions, operators and crews of the PersistenceI have used the seawater circulation system with resultant flooding that compromised the safety of the crew and vessel. Fitting-out of Live-well Tanks A seawater circulation system is used to preserve the catch; however, the water retained in the live-well tank creates a free surface effect that has a direct impact on the vessel's stability. The SFVIR do not contain specific provisions governing the fitting-out of live-well tanks. Moreover, unless they are fishing for herring or capelin, owners of small fishing vessels are not required to learn more about the stability of their vessel by meeting two conditions: conduct an inclining experiment and produce a stability booklet. If live-well tanks were fitted out on the PersistenceI, the regulator required that those two conditions be met. The first owner did not comply and an annotation was added to the inspection certificate. It was not possible to determine how many times the seawater system had been used. The history of this vessel shows that this administrative procedure did not produce the desired results. A physical barrier preventing the use of the system would have better reduced the risks. Salt Water Circulation System for Live-well Tanks and Safety The live-well tanks are a significant safety component affecting the safe operation of the vessel. While the SFVIR do not require submission of plans for approval of seawater circulation to live-well tanks, Section 48 empowers inspectors to request such information to ensure that the vessel is seaworthy for its intended use. However, this was not done. Bilge Pumping System and Bulkhead Integrity Neither the crew's messroom nor the aft compartment that includes the live-well tanks and the lazarette are equipped with bilge suctions connected to a drainage pump. However, according to the regulations, all watertight compartments in a fishing vessel such as the PersistenceI must be equipped with at least one bilge suction mechanism to discharge water outside the vessel. If the trim had worsened to the point that flooding occurred in the vessel's bow, the crew would not have been able to drain the forward compartment. Therefore, the potential existed for the vessel to lose reserve buoyancy and sink. Although there is a drainage mechanism in the aft compartment, water is not discharged overboard, but into the fish hold. Transferring the water from one compartment to another creates a free surface effect in the second compartment. This particular design has a direct impact on the vessel's stability. Closing the sluice valves only seals the bulkhead temporarily. This design does not follow the principle of compartmentation, which is based on a subdivision comprising permanent watertight transverse bulkheads. High Water Level Alarm System Examination The high water level alarm system was examined after the occurrence. Once turned on, the alarm was armed even though the compartments were dry. This indicates that the system was off when the flooding took place. PersistenceI Certification Since the PersistenceI was subject to the provisions of the SFVIR when it was designed and built, the owner or builder had to conform to a clearly defined submission and approval process. The information concerning the seawater circulation system for the live-well tanks was not presented in triplicate and was, thus, not properly approved. In other words, the information does not seem to have been processed by the Technical Services Division, but rather by the inspector responsible for the inspection. This information was essential for those who were mandated to verify the vessel's plans or documentation. In issuing the inspection certificate, the inspector did not fully take into account the red annotations on the plans. The inspection certificate was issued for four years, which is a full term, based on incomplete information. However, there is a provision that permits inspectors to issue a short-term certificate. Issuing a short-term certificate and an accompanyingSI7 identifying safety shortcomings allows owners to address safety-related items in a reasonable time frame. It also allows TC to follow up and ensure that the identified deficiencies have been satisfactorily addressed. Like most new vessel inspections, the inspection of the PersistenceI required several shipyard visits. All the visits were conducted by the inspector who was assigned to the sector of the district in which the shipyard was located. In this instance, a multi-disciplinary approach was not used and the field inspection did not benefit from a full assessment of the approved plan, which included the notation requesting additional watertight bulkhead and additional safeguards with respect to the fitting of the live-wells tanks. Given the regulatory requirements, it is important that qualified inspectors be assigned to carry out inspection during construction and/or modification of the vessel. In some TCdistricts, for example in the Laurentian region, assistance has been sought from specific disciplines in the interest of marine safety. Information Transfer Between Regions Since February 2000, TC has included a letter of accompaniment with every certificate of registry issued to owners/operators that contains this statement: should your address change or your vessel undergo any modifications, you must inform the nearest Registrar of Ships. An internal administrative measure was added in September2003 that requires registrars of ships to report ownership transfers to the Marine Safety Branch in their respective regions. This measure is designed to inform inspectors of transfers of ownership and to allow the Department to promote safety by contacting the new owners/operators to inform them of the requirements concerning operation and inspection of their vessels. Although TC had implemented two measures to ensure proper follow-up of files for each vessel registered in Canada, these measures did not yield positive results. At the time of the occurrence, the vessel's file was still in the Maritimes region. It was not until after the occurrence that the Marine Safety Branch at the TC Centre in Qubec became aware of the file. Accordingly, information about the vessel's history and pre-existing data was not readily available to the inspector to inform the inspection. The crew started the seawater circulation system without knowing how to use it, and in contradiction to the prohibition imposed by Transport Canada on the vessel's certificate. Due to gravity, a gradual flow of water ran from the live-well tanks to the fish hold and then to the lazarette because the sluice valves connecting these compartments were all open. When the six discharge outlets in the transom became submerged subsequent to the pronounced trim by the stern, seawater flowed into the live-well tanks through these outlets, thereby increasing the rate of flooding. Downflooding also occurred when the fish hold hatch cover fell overboard.Findings as to Causes and Contributing Factors The crew started the seawater circulation system without knowing how to use it, and in contradiction to the prohibition imposed by Transport Canada on the vessel's certificate. Due to gravity, a gradual flow of water ran from the live-well tanks to the fish hold and then to the lazarette because the sluice valves connecting these compartments were all open. When the six discharge outlets in the transom became submerged subsequent to the pronounced trim by the stern, seawater flowed into the live-well tanks through these outlets, thereby increasing the rate of flooding. Downflooding also occurred when the fish hold hatch cover fell overboard. The majority of small fishing vessels operate under circumstances whereby Transport Canada does not have to require those operating them to hold fishing master certificates. Consequently, many fishers do not have the necessary knowledge of shipboard operational requirements, including knowledge of stability, to operate their vessels safely. In the absence of a risk management system, the company could not fully assess its risk exposure, nor was it able to define and implement appropriate preventive measures to eliminate or reduce the consequences of the risks involved. Transport Canada's inspection regime did not identify the shortcomings in the vessel's bilge pumping system, and the drainage of water from one compartment to another was not fitted with a pump, which negated the benefit of the vessel's subdivision requirement. Deploying Transport Canada inspectors to inspect vessels when they are not qualified in the inspection-related discipline may lead to decision making based on incomplete information, thereby increasing the risk to fishing vessel safety. The administrative measures implemented by Transport Canada for proper transfer of fishing vessel files between regions are not always followed. Consequently, the information about a vessel's history and pre-existing conditions may not be readily available to the inspector to inform the inspection.Findings as to Risk The majority of small fishing vessels operate under circumstances whereby Transport Canada does not have to require those operating them to hold fishing master certificates. Consequently, many fishers do not have the necessary knowledge of shipboard operational requirements, including knowledge of stability, to operate their vessels safely. In the absence of a risk management system, the company could not fully assess its risk exposure, nor was it able to define and implement appropriate preventive measures to eliminate or reduce the consequences of the risks involved. Transport Canada's inspection regime did not identify the shortcomings in the vessel's bilge pumping system, and the drainage of water from one compartment to another was not fitted with a pump, which negated the benefit of the vessel's subdivision requirement. Deploying Transport Canada inspectors to inspect vessels when they are not qualified in the inspection-related discipline may lead to decision making based on incomplete information, thereby increasing the risk to fishing vessel safety. The administrative measures implemented by Transport Canada for proper transfer of fishing vessel files between regions are not always followed. Consequently, the information about a vessel's history and pre-existing conditions may not be readily available to the inspector to inform the inspection. The crew of the PersistenceI expressed interest in participating in the training program for fishers and fisher's helpers (Programme de professionnalisation des pcheurs et aides-pcheurs); however, the company had not introduced a mechanism to ensure full participation. Since the flooding could not be controlled, the crew decided to beach the vessel to facilitate the marine salvage. The number of persons on board exceeded the capacity of the liferaft.Other Findings The crew of the PersistenceI expressed interest in participating in the training program for fishers and fisher's helpers (Programme de professionnalisation des pcheurs et aides-pcheurs); however, the company had not introduced a mechanism to ensure full participation. Since the flooding could not be controlled, the crew decided to beach the vessel to facilitate the marine salvage. The number of persons on board exceeded the capacity of the liferaft. Safety Action Taken Marine Safety Information Letter Subsequent to reports of numerous flooding occurrences, the Board sent Marine Safety Information Letter (MSI) 04/04 to Transport Canada (TC) on 07 July 2004 informing of its concerns about the seawater circulation system for live-well tanks. In response to MSI 04/04, TC informed the TSB on 08 September 2004 of its intention to require stability calculations and modifications to the PersistenceI. In addition, vessels of similar construction would be given special attention. Stability Booklet Required for the PersistenceI On 23 November 2004, TC informed the owner, pursuant to Paragraph 377(2) of the Canada Shipping Act, that the inspection certificate issued on 09July2001 was no longer valid.12 Pursuant to a directive concerning the stability of small fishing vessels issued in 2005by the TC Centre in Qubec, the Marine Safety Branch required that the owner conduct an inclining experiment and produce a stability book. The owner was notified that failure to comply would result in detention of the vessel. Transport Canada-Stability Data The Board, concerned about the stability of small fishing vessels, has made three recommendations to TC. Recommendations M03-05 and M03-06 called for stability data assessment/verification of small fishing vessels.13 In response to a follow-up recommendation, M05-04 (issued in November2005), TC issued Ship Safety Bulletin (SSB)04/2006, titled Safety of Small Fishing Vessels: Information to Owners/Masters about Stability Booklets. With this bulletin, TC has established a nationally consistent baseline for applying Section48 of the Small Fishing Vessel Inspection Regulations requiring a stability booklet to be on board all vessels that are at risk. The risk factors have been identified in the Stability Information Questionnaire for a Commercial Fishing Vessel, which is attached to the SSB and which owners are required to complete. Additionally, TC has drafted a new standard for small fishing vessels under 24m in length (Stability, Freeboard, Load Limit and Associated Seaworthiness-Small Fishing Vessels under 24Metres in Length) for consideration by the industry. This draft presents criteria for stability assessment including consideration of the free surface effects associated with live-well tanks. Post-occurrence Vessel Modifications When the PersistenceI was modified in the winter of 2004/2005, the following changes were made to the vessel: the seawater circulation system for the live-well tanks was removed; the six pipes, discharge valves, and outlets on the transom were removed; the bilge suctions in the live-well tanks and lazarette were connected to the fish hold pump, and a strainer was installed on each of the bilge suctions; the high water alarm system was checked and tested to the satisfaction of the regulator; and the height of the sill to the door that accesses the superstructure from the afterdeck was raised to 300mm. Development of a Safety Culture in the Fishing Industry TC has informed the Board that it is committed to assisting in the development of a safety culture in the fishing industry. TC realizes that regulations and standards are not the only approach required to address the issue of small fishing vessel safety. TC has conducted safety awareness campaigns by distributing safety booklets, such as the Small Fishing Vessel Safety Manual (TP10038E) and has also partnered with the Fish Harvesters Resource Centre in Newfoundland and Labrador to air small fishing vessel safety tips on local television programs. TC also supported an initiative with the Nova Scotia fishing sector to produce a safety publication called Fish Safe -A Handbook for Commercial Fishing and Aquaculture, which has been widely distributed in Nova Scotia. TC has stated that it is aware of the importance and value of a safety culture within the fishing industry. Recognizing that the master and crew of a fishing vessel make safety decisions every day, communication efforts are under way to provide fishers with information to help them make good choices. Fishers Training Initiative TC, in conjunction with other stakeholders including the Workers' Compensation Board of British Columbia and the Canadian Council of Professional Fish Harvesters, is developing a course to address fishing vessel stability.